Coroner David Ryan says police had 'clearly not followed' custody management procedures on February 5, 2021, when they kept Darren Ricky Culleton, 31, inside a divisional van for 48 minutes.
Officers sat in the front seat of the van and failed to realise Mr Culleton had choked on the hood of police-issued coveralls he was wearing and blacked out."Darren's death in custody was a preventable tragedy," Mr Ryan said.
"The signs of his anguish were glaring, impossible to ignore, and yet, nobody cared enough to intervene," they said. Mr Culleton, who was out on bail, was then immediately arrested by police who wanted to question him over alleged shoplifting offences.The inquest heard police quickly abandoned those plans because of Mr Culleton's agitated state, and officers decided to move him to the custody centre where there was better supervision.
Mr Ryan said the officers could not have foreseen that Mr Culleton would choke himself by eating his clothing, and said it was understandable for them to think he had fallen asleep or calmed down when he stopped moving in the van.In his recommendation for a Victoria Police policy on the use of coveralls, Mr Ryan said it must be made clear "that they should not be used in conjunction with a suicide-resistant gown".
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